General Approach to Assessment of Psychiatric Patients Joe Marie Jardiolin, MD, FPCEM, FACEM Liverpool and Fairfield Hospital March 2016

SACCIT six essential processes in MH after triage Safety Assessment Confirmation of Provisional Diagnosis Consultation Immediate Treatment Transfer of Care Mental Health for Emergency Departments: A Reference Guide. NSW Health 2015

SAFETY Ensuring that the patient’s risk of harm to self and others are well managed during the duration of their ED stay

Assessment Clear and reliable History MENTAL STATE EXAMINATION Vital Signs Physical Examination RISK ASSESSMENT ( risk of harm to self/others, risk of absconding, risk of missed organic illness

Confirmation of Provisional Diagnosis obtaining the vital information to assist in reaching a provisional or working diagnosis 2 essential elements: Obtaining corroborative History ( Collateral History) Investigations to include or exclude organic cause

Consultation ED Consultant initially Accessing early the Mental Health Service /PECC C/L Psychiatry Drug and Alcohol ICAMHS ( infant child adolescent MHS) Rural services

Immediate Treatment Providing the right intervention Organic treatment – medication, sedation, treat underlying cause (?infection, delirium) Psychological – de-escalation, therapeutic engagement, counseling Social – mobilizing support from family, community care, social worker/emergency accommodation

Transfer of Care Ensuring safe and easy transfer of care to: Inpatient teams ( Medical or Psych) Community (GP, psychiatrist, ComMHET)

MENTAL STATE EXAMINATION A - Appearance B - Behaviour C - Cooperation Mood and Affect Speech Thought Form Thought Content Perception Cognition Insight Judgment

MSE APPEARANCE BEHAVIOUR Posture Body appearance and general condition grooming BEHAVIOUR Mannerisms, tics Agitation, restlessness, aggressive passive

MSE COOPERATION Friendly or extreme friendliness Cooperative or uncooperative Suspicious, hostile Evasive Seductive perplexed

MSE MOOD AFFECT Patient description of how they fell ?Depressed ?Excited / elated AFFECT Clinician’s observation of patient appropriateness of patient’s emotion Patient says he’s sad but is smiling

MSE SPEECH Rate – fast, slow Volume – loud, soft Quantity – pressured, non verbal, talkative Quality – accent, rhythm

MSE THOUGHT FORM THOUGHT CONTENT Poverty of content, racing thoughts Flight of ideas, incoherence. tangential THOUGHT CONTENT Delusions Pre-occupations Obsession / compulsion

MSE PERCEPTION Hallucinations ( especially auditory) Delusions Paranoid thoughts Heightened perception

MSE COGNITION Level of Consciousness Memory Orientation Attention and Concentration Mini Mental State exam

MSE INSIGHT Patients awareness of their illness ( poor, partial or good) JUDGEMENT Patient ability to assess situation and act appropriately

THANKS ?QUESTIONS

Reference Mental Health for Emergency Departments: A Reference Guide. NSW Ministry of Health 2015 Mental Health Act 2007